Deficient Medication Storage, Labeling, and Accountability Practices
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management and storage practices. In the medication room, expired tube feeding formulas and unlabeled medical supplies, such as anti-embolic stockings, suction catheter trays, and tracheostomy care kits, were found. These items lacked use-by dates or were past their expiration, and the DON confirmed that such items should have been disposed of according to facility policy. The facility's policy requires routine checks and removal of expired or opened items, which was not followed. Further observations in medication carts revealed additional deficiencies. In medication cart A1, non-narcotic medications were stored in the narcotic cabinet, expired and unsealed medications were present, and medications belonging to discharged residents were not removed. Some medications, such as Doxycycline and Famotidine, were found in cups without resident labels or original packaging. Treatment supplies were also stored in the medication cart instead of the designated treatment cart. The pharmacy consultant and DON confirmed these practices were not in line with facility policy and could lead to medication errors. In medication cart A2, opened over-the-counter medications lacked open and discard dates, and the narcotic count sheet was missing required signatures from both incoming and outgoing licensed nurses. Facility policy mandates that all opened medications be labeled with the date opened and that narcotic count sheets be signed by both shifts to ensure accountability. These lapses in documentation and storage practices were confirmed by interviews with nursing staff and the DON.